Healthcare Provider Details

I. General information

NPI: 1073160214
Provider Name (Legal Business Name): JEREMIAH C BUENROSTRO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2019
Last Update Date: 05/08/2024
Certification Date: 03/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

393 E WALNUT ST
PASADENA CA
91188-1486
US

IV. Provider business mailing address

18646 OXNARD ST
TARZANA CA
91356-1411
US

V. Phone/Fax

Practice location:
  • Phone: 877-457-4772
  • Fax:
Mailing address:
  • Phone: 818-996-1051
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number120503
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number96364
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: